a nurse is caring for a client who came to the emergency department reporting chest pain the provider suspects a myocardial infarction while waiting f
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Nursing Elites

ATI RN

ATI Nursing Specialty

1. A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the laboratory to report the client's troponin levels, the client asks what this blood test will show. The nurse should explain that troponin is

Correct answer: a heart muscle protein that appears in the bloodstream when there is damage to the heart.

Rationale: The correct answer is that troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a specific marker for heart muscle damage, particularly seen in conditions like myocardial infarction. Choice A is incorrect as troponin is not an enzyme that indicates damage to brain and skeletal muscle tissues. Choice B is incorrect as troponin is not a protein whose levels reflect the risk for coronary artery disease; it indicates heart muscle damage. Choice D is incorrect as troponin is not a protein that helps transport oxygen throughout the body; its presence in the bloodstream is specific to heart muscle damage.

2. Which intervention will best help a patient with chronic pain maintain mobility?

Correct answer: B

Rationale: Encouraging stretching exercises is the most appropriate nursing intervention to help a patient with chronic pain maintain mobility. Stretching exercises can improve flexibility, prevent stiffness, and promote better range of motion in patients with chronic pain. Providing opioids (Choice A) may help control pain but does not directly address mobility. Teaching the patient to use assistive devices (Choice C) may be beneficial but does not focus on improving mobility directly. Recommending complete bed rest (Choice D) can lead to deconditioning and further loss of mobility, which is not recommended for chronic pain management.

3. Are the oral, nasal, orbital, and middle ear cavities in the dorsal cavity?

Correct answer: False

Rationale: The correct answer is False. The oral, nasal, orbital, and middle ear cavities are actually part of the ventral cavity, not the dorsal cavity. The dorsal cavity contains the cranial and spinal cavities, while the ventral cavity includes the thoracic, abdominal, and pelvic cavities. Therefore, these structures are located in the ventral cavity, not the dorsal cavity. Choices A, C, and D are incorrect because these structures are not situated in the dorsal cavity.

4. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

5. A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

Correct answer: C

Rationale: The correct answer is to gently inquire about advance directives. Superior vena cava syndrome is often a late-stage manifestation, indicating a serious condition. Discussing advance directives with the client is crucial to ensure their wishes are known in case of deterioration. Administering allopurinol (Choice A) is not indicated for superior vena cava syndrome. Assessing the client’s serum potassium level (Choice B) is not the priority when managing this syndrome. Emergency surgery (Choice D) is not typically the initial treatment for superior vena cava syndrome.

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